PCD TRAINING MANUAL. What is PCD?? “Patient Care Documentation” Computerized nursing documentation Developed by Siemen’s Company Used on all hospital.

PCD TRAINING MANUAL

What is PCD??

“Patient Care Documentation”

Computerized nursing documentation

Developed by Siemen’s Company

Used on all hospital units except for the ED, Labor & Delivery, Post partum, NICU, and PICU.

Limited use in the Adult ICU - use the admission history section only.

System Sign-on

The User ID & password is your legal signature.Contact the Help Desk (4-2501) if you want to change your password.Never allow anyone else to use your password.Always log off when the transaction is complete.A record is kept of all transactions.

System Sign-on

User ID and Password will be issued to you by your faculty.

All student IDs will begin with NST. Use only while you are at S&W as a student.

Security Students who are also employees of

Scott & White

If you are a student and an employee, you will have a User ID and password for each role.

While you are at Scott & White as a student, use the User ID that begins with NST.

Do not use this ID when you are at Scott & White as an employee.

While you are at Scott & White as an employee, use the User ID that was provided through Human Resources. Do not use this ID when you are at Scott & White as a student.

Accessing information using the incorrect User ID, is grounds for termination of employment, and clinical privileges

Nurse Station Census

The unit census defaults to where the user signs on.

Net Access navigator bar.Can be used to locate patientsby name or MRN inquiry.

Nurse Station Census

Patients are listed in Room/Bed order, Name highlighted in blue and underlinedClick once on the patient name to select patient.

View census of another unit by selecting Unit Census from the Navigator Bar and choosing the unit

More Navigator Facts Once a patient is selected different functions are available.

The patient’s name and the user ID display at the top of the screen

Items preceded by a sphere display multiple options when item is selected

Vital Signs

Charting Vital Signs

Defaults to current time, may change date and time.Can NOT chart in the future

Use spin buttons or type In the values

Move from field to field using mouse or tab key

Charting Vital Signs

To add more vital signs,Click here. Click update complete to chart

Click on cancel to exit pathway without entering data.

Revise Vital Signs

Indicates the person Entering the data

Vital signs are grouped in reverse chronological order.

Revise Vital Signs

From the vital display, select vs to be revised Then click on revise.

Revise/Delete Vital Signs

Choose radio button:1. Revise result to change incorrect data on correct patient.2. Mark as error to delete data entered on wrong patient.Once chosen, fields are enabled to allow revision. Make changes andClick OK

When using Mark as Error,A reason must be entered.

Using skip button allows userTo leave screen without makingChanges.

Display Vital Signs

This displays the last 5 sets of VS. To see all since admission, click all.

Revised VS will display this way

Vital Signs mark as an error display this way

Intake and OutputI&O

Entering I&O

Enter the date/ time I & O collected

Enter amount of intake or output in mls

Select box in front of source to delete a source that is no longer needed. The box will be grayed out if data has been entered in the last 24 hours

Exclude sources are not included in the I/O totals.An “X” will display in the Excld column. IE Stool Count

Click OK to store data

Select Add Comments to Enter additional data about I&0

Comments

A comment field is providedFor each I&O sourceClick OK when completed

Intake & Output Sources

Select intake or output to add sources

Click Add when desired sources have been selected

Revise I&O

Only licensed staff can revise

Select the item(s) to be revisedClick revise

Shows the date/time interval for the displayed data.

T indicates comment

Revise I&O

Choose radio button:1. Revise result to change incorrect data on correct patient.2. Mark as error to delete data entered on wrong patient.Once chosen, fields are enabled to allow revision. Make changes andClick OK

When using Mark as Error,A reason must be entered.

Using skip button allows userTo leave screen without makingChanges.

Display I & O

Shift times in columns link to additional information

T indicates a comment was addedSources marked exclude will not show in the total

CMST ChecksRestraint Documentation

CMST Checks

Document Restraint data here

Change date/ time as needed to reflectrequired q 2 hour restraint documentation.

Items click yes require description

Document interventions every 2 hours and add comments as needed

Click update complete to store data

Chart Assessments

Admission/Shift/Focus Assessment

Create New Assessment

LVNs do not have discharge assessment listed.

Select assessment type and click begin

Date and time should reflectactual date and time assessment was performed.

Admission Assessment

From this screen document Admission History, Admission assessment, and other needed assessments, ie, pain/ comfort or restraints.

Selecting ‘Required Assessments’ automatically selects all the Admission History, Body Systems, Fall Risk, and Education. Others may be selected as needed. Each system displays in the order they appear on this screen.

Select chart detail to continue

Last chance to modify date and time.

Admission History

Opt Out is a mandatory field

Arrival Date/Time must be entered

Ask the patient each question in the admission history. Only applicable data is actually entered into the system.

‘…’ indicates additional screens will appear if the item is selected

Admission History Personal Belongings

You must describe clothing, cash, jewelry, other Location is mandatoryif the field is selected

Use these buttons to move between screens

Admission HistoryNutritional Screening

Selecting any of these will send a consult to Nutrition Services

Not required but useful information

Admission HistoryChaplain Referral

Selecting chaplain referral will generate consult

These fields are mandatory.Cannot move forward until completed

Admission HistoryContinuum of Care

Anticipated discharge placement

Selecting any of these will generate a referral

Admission HistoryAdvance Directives

Executed Advance Directives is a required field

Admission HistoryPast Medical/Surgical History

Be sure to assess immunization status on admissionClick on Pneumo/Inf to access the Admission AssessmentHospital Order form and immunization information.

LVNs may only select Update PendingUpdate Complete will be grayed out

Enter date of vaccination if known,You can check DWP for immunization date status if unknown.

This screen allows you to collect data regarding existing conditions that may affect the care during this admission.

RN’s – select continue to move on to physical assessment.

AssessmentWithin Defined Limits (WDL)

“WDL All” indicates your assessment meets the defined limitsSelect “except for” to document exceptions to WDL.

Assessment Cardiovascular

Most selections can be entered via the point and click method using the radio buttons,Checkboxes and free-text data entry fields

AssessmentEdema

Click the “Grade” buttonfor definitions

AssessmentBraden Scale

Braden scale must be assessed every 24 hours

Document any skin abnormality from this screen

Braden Scale

Click here to access skin care policy

Select either tab or button

Select appropriate descriptor or free text number in box

Click “Close” or “Continue” to see Braden total score

AssessmentFall Risk

You must select either “no fall risk” or one or more of the risk factors listed to proceed.

Click here to access fall prevention guidelines.

Assessment Storing Data

Select update/complete or update/pendingto save entered data

Assessments that were visited are underlined

Shift/Focus Assessments

Admission History not an option on this screen

Required assessments include body systems, fall risk and education

Other options, ie, Peripheral IV, Pain/Comfort, etc. may be added as appropriate

All other steps are the same as the admission assessment

Shift/Focus Assessments

If Shift or Focus Assessment is selected this screen will appear. Admission History is not an option. ‘Required Assessments’ automatically selects all the Body Systems, Fall Risk, and Education. Others may be selected as needed. Each system displays in the order they appear on this screen.

Select chart detail to continue

View Assessments

Click to view assessment, select assessmentand click view.

View Assessment

This is how datadisplays when View Assessments selected

Change/Delete Assessment

Select the assessment to be changedor deleted, then click the appropriate button for that function.

Change Assessment

Only change your own assessments

Guidelines for Change Assessment

Use Change when you need to modify an existing assessment that you have created. This will not create a new assessment or change the date and time of the original assessment.

Delete Assessment

This is the final screen before you delete an assessment

Only delete your own assessments.

Guidelines for Delete Assessment

Use Delete when you have charted on the wrong patient.

Delete only your own assessments

Copy Assessment

Select copy an existing assessment Select assessment to be copied.Click copy.

Guidelines for Copy an Existing Assessment

Use Copy when you want to create a new assessment based on a previous assessment of the same type. For example, you need to perform a Respiratory Assessment every four hours. Select ‘Copy an Existing Assessment’. Then, select the assessment you wish to copy. Review the information in the assessment and change those values that are different from the previous assessment. This will create a new assessment but not alter the assessment that was copied.

Complete Pending Assessment

Select complete assessment, choose assessment in pending status (P), and click complete.

Discharge Assessment

Enter date/time the patient left the unit. Not the time of the discharge order

Click continue to move to next screen

Discharge Assessment

This question asks if immunization status was assessed.

Indicates administration of vaccine

Document discharge education, patient response, and pain status at time of discharge

Patient Notes

Patient Notes is the opportunity to include a narrative note referring to patient care issues not addressed by any assessment pathway. Ex. Response to treatment, untoward events—falls, codes, etc.-- or Nursing Diagnoses not addressed in assessment pathways

Take ever opportunity to learn.

Be safe out there!